Families affected by catastrophic costs due to tuberculosis
Authors: Malaisamy Muniyandi
Journal: The Lancet Global Health (2023)

The high household costs associated with tuberculosis diagnosis and treatment can create barriers to access and adherence. One of WHO's End TB Strategy targets states that no tuberculosis-affected household should face catastrophic costs—that is individuals with tuberculosis (or their households) having to spend a substantial portion of their income to treat or diagnose tuberculosis. To estimate the occurrence of catastrophic cost (defined as >20% of household income or expenditure) associated with tuberculosis diagnosis and treatment in low-income and middle-income income countries (LMICs), Alison Portnoy and colleagues1Portnoy A Yamanaka Y Nguhiu P Costs incurred by people receiving tuberculosis treatment in low-income and middle-income countries: a meta-regression analysis.Lancet Glob Health. 2023; 11: e1640-e1647Google Scholar carried out a meta-regression analysis. In their paper, published in The Lancet Global Health, they show that 54·9% of tuberculosis-affected households experience catastrophic costs due to tuberculosis diagnosis and treatment, with poorer households more likely to experience catastrophic expenditure than richer ones. After WHO's End TB Strategy, endorsed by the 67th World Health Assembly in 2014, WHO promoted universal health coverage, emphasising the need for access to services at an affordable cost to protect households from catastrophic health expenditures. Policy makers have designed many interventions to provide financial protection to patients with tuberculosis. However, there is still a financial burden for patients with tuberculosis in LMICs. Further studies from LMICs suggest that health-care payments increase the risk of poverty and affect the poorest the most. Portnoy and colleagues,1Portnoy A Yamanaka Y Nguhiu P Costs incurred by people receiving tuberculosis treatment in low-income and middle-income countries: a meta-regression analysis.Lancet Glob Health. 2023; 11: e1640-e1647Google Scholar by using a meta-regression analysis, provide a synthesised perspective on costs, and predict the economic implications for 135 LMICs by combining Bayesian approaches with data from 22 national surveys.1Portnoy A Yamanaka Y Nguhiu P Costs incurred by people receiving tuberculosis treatment in low-income and middle-income countries: a meta-regression analysis.Lancet Glob Health. 2023; 11: e1640-e1647Google Scholar This study offers crucial insights for policy makers and health-care practitioners striving to create effective and equitable health-care interventions in resource constrained settings. The findings contribute substantially to understanding the broader socioeconomic challenges associated with tuberculosis care in LMICs. In a different study, Siapka and colleagues2Siapka M Vassall A Cunnama L et al.Cost of tuberculosis treatment in low- and middle-income countries: systematic review and meta-regression.Int J Tuberc Lung Dis. 2020; 24: 802-810Crossref PubMed Scopus (11) Google Scholar took a provider's perspective, giving a comprehensive analysis of the costs associated with treating patients with tuberculosis. Notably, the predicted median costs per 6 months of treatment, for providers, vary from US$315 for low-income countries, to $527 for LMICs, and $896 for upper-middle-income countries. Patient costs reported by Portnoy and colleagues, per patient per episode of tuberculosis was US$1253.1Portnoy A Yamanaka Y Nguhiu P Costs incurred by people receiving tuberculosis treatment in low-income and middle-income countries: a meta-regression analysis.Lancet Glob Health. 2023; 11: e1640-e1647Google Scholar Despite the availability of free diagnosis and treatment for tuberculosis, there are substantial costs incurred by patients and their families. This influences adverse treatment outcomes and has a bidirectional relationship with poverty. The high indirect costs are due to poor health and an inability to work and generate income. Households with the lowest income are further affected by the unexpected health expenditure on treatment making the households poorer. This financial burden warrants a social health insurance scheme that enables an increased level of health insurance coverage to all households and allows the poorest to access health care without the risk of catastrophic health expenditure. Since various studies have reported the patient costs incurred for tuberculosis, including catastrophic costs, hospitalisation costs, and other associated costs through national surveys, prediction models, and systematic reviews and meta-analyses, implementation of inventions and strategies to reduce catastrophic costs is essential.3Tanimura T Jaramillo E Weil D Raviglione M Lönnroth K Financial burden for tuberculosis patients in low- and middle-income countries: a systematic review.Eur Respir J. 2014; 43: 1763-1775Crossref PubMed Scopus (351) Google Scholar, 4Madan J Lönnroth K Laokri S Squire SB What can dissaving tell us about catastrophic costs? Linear and logistic regression analysis of the relationship between patient costs and financial coping strategies adopted by tuberculosis patients in Bangladesh, Tanzania, and Bangalore, India.BMC Health Serv Res. 2015; 15: 476Crossref PubMed Scopus (0) Google Scholar, 5Ghazy RM El Saeh HM Abdulaziz S et al.A systematic review and meta-analysis of the catastrophic costs incurred by tuberculosis patients.Sci Rep. 2022; 12: 558Crossref PubMed Scopus (21) Google Scholar Active case finding is one intervention that could result in reduced delays before diagnosis, prevent disease transmission in the community, and reduce direct and indirect costs for patients and households.6Muniyandi M Thomas BE Karikalan N et al.Catastrophic costs due to tuberculosis in South India: comparison between active and passive case finding.Trans R Soc Trop Med Hyg. 2020; 114: 185-192Crossref PubMed Scopus (0) Google Scholar LMICs should also develop public health systems or social insurance systems that cover the out-of-pocket expenditure to patients and their families. In addition, introducing new digital technological interventions and novel approaches such as 99DOTS (a low-cost solution for tuberculosis medicine adherence),7Chen AZ Kumar R Baria RK Shridhar PK Subbaraman R Thies W Impact of the 99DOTS digital adherence technology on tuberculosis treatment outcomes in North India: a pre-post study.BMC Infect Dis. 2023; 23: 504Crossref Scopus (0) Google Scholar video-supported home-based tuberculosis care, video-observed therapy, and an eHealth portal could also reduce catastrophic costs to patients with tuberculosis. I declare no competing interests. Costs incurred by people receiving tuberculosis treatment in low-income and middle-income countries: a meta-regression analysisTuberculosis diagnosis and treatment impose substantial costs on affected households. Eliminating these economic losses is crucial for removing barriers to accessing tuberculosis diagnosis and completing treatment among affected households and achieving the targets set in WHO's End TB Strategy. Full-Text PDF Open Access